OFFICE OF STATEWIDE HEALTH PLANNING AND DEVELOPMENT EMERGENCY DEPARTMENT

Transcription

OFFICE OF STATEWIDE HEALTH PLANNING AND DEVELOPMENT
EMERGENCY DEPARTMENT
MANUAL ABSTRACT REPORTING FORM
Effective with Encounters on or after July 1, 2014
Page 1 of 3
Instructions: For a description of the data elements, refer to the appropriate section of the Patient Data Reporting Requirements
(Title 22, Sections 97251 through 97265, and 97267)
FACILITY ID NUMBER
DATE OF BIRTH
Month
Day
Year (4-digit)
ZIP CODE
ABSTRACT RECORD NUMBER (Optional)
SEX
F Female
M Male
U Unknown
RACE
R1 American Indian or Alaska Native
R2 Asian
R3 Black or African American
R4 Native Hawaiian or Other Pacific Islander
R5 White
R9 Other Race
99 Unknown
ETHNICITY
E1 Hispanic or
Latino
E2 Non-Hispanic
or Non-Latino
99 Unknown
PATIENT'S SOCIAL SECURITY NUMBER
99999 = Unknown
Report 000000001 (Unknown) if not recorded in the patient's medical record
SERVICE DATE
Month
Day
Year (4-digit)
PREFERRED LANGUAGE SPOKEN
Enter a valid 3-letter PLS Code from either OSHPD's list of PLS Codes in the ED & AS Reporting Manual, Section 97267;
or from the ISO 639-2 Code List at www.loc.gov/standards/iso639-2
If the patient's language is not included in either of these lists, then enter the language spoken in the space provided.
EXPECTED SOURCE OF PAYMENT
09
11
12
13
14
16
AM
BL
CH
CI
Self Pay
Other Non-federal programs
Preferred Provider Organization (PPO)
Point of Service (POS)
Exclusive Provider Organization (EPO)
Health Maintenance Organization (HMO) Medicare Risk
Automobile Medical
Blue Cross/Blue Shield
CHAMPUS (TRICARE)
Commercial Insurance Company
OSHPD 1370.ED
DS Disability
HM Health Maintenance Organization
MA Medicare Part A
MB Medicare Part B
MC Medicaid (Medi-Cal)
OF Other Federal program
TV Title V
VA Veterans Affairs Plan
WC Workers' Compensation Health Claim
00 Other
Revised May 1, 2014
Page 2 of 3
DISPOSITION OF PATIENT
01
02
03
04
05
06
07
20
21
43
50
51
61
62
63
64
65
66
70
00
Discharged to home or self care (routine discharge)
Discharged/transferred to a short term general hospital for inpatient care
Discharged/transferred to skilled nursing facility (SNF) with Medicare certification in anticipation of covered skilled care
Discharged/transferred to a facility that provides custodial or supportive care (includes Intermediate Care Facility)
Discharged/transferred to a designated cancer center or children’s hospital
Discharged/transferred to home under care of organized home health service organization in anticipation of covered skilled care
Left against medical advice or discontinued care
Expired
Discharged/transferred to court/law enforcement
Discharged/transferred to a federal health care facility
Discharged home with hospice care
Discharged to a medical facility with hospice care
Discharged/transferred to a hospital-based Medicare approved swing bed
Discharged/transferred to an inpatient rehabilitation facility (IRF) including a rehabilitation distinct part unit of a hospital
Discharged/transferred to a Medicare certified long term care hospital (LTCH)
Discharged/transferred to a nursing facility certified under Medicaid (Medi-Cal), but not certified under Medicare
Discharged/transferred to a psychiatric hospital or psychiatric distinct part unit of a hospital
Discharged/transferred to a Critical Access Hospital (CAH)
Discharged/transferred to another type of health care institution not defined elsewhere in this code list
Other
PRINCIPAL DIAGNOSIS
ICD-9-CM CODE
OTHER DIAGNOSES
ICD-9-CM CODE
a.
g.
m.
s.
b.
h.
n.
t.
c.
i.
o.
u.
d.
j.
p.
v.
e.
k.
q.
w.
f.
l.
r.
x.
OTHER EXTERNAL CAUSES OF MORBIDITY
ICD-9-CM CODE
PRINCIPAL EXTERNAL CAUSE OF MORBIDITY
ICD-9-CM CODE
E
OSHPD 1370.ED
a.
E
b.
E
c.
E
d.
E
Revised May 1, 2014
Page 3 of 3
PRINCIPAL PROCEDURE
CPT-4 CODE
OTHER PROCEDURES
CPT-4 CODE
a.
k.
b.
l.
c.
m.
d.
n.
e.
o.
f.
p.
g.
q.
h.
r.
i.
s.
j.
t.
OSHPD 1370.ED
Revised May 1, 2014
AMBULATORY SURGERY
Page 1 of 3
FACILITY ID NUMBER
DATE OF BIRTH
Month
Day
Year (4-digit)
ZIP CODE
ABSTRACT RECORD NUMBER (Optional)
SEX
F Female
M Male
U Unknown
RACE
R1 American Indian or Alaska Native
R2 Asian
R3 Black or African American
R4 Native Hawaiian or Other Pacific Islander
R5 White
R9 Other Race
99 Unknown
ETHNICITY
E1 Hispanic or
Latino
E2 Non-Hispanic
or Non-Latino
99 Unknown
PATIENT'S SOCIAL SECURITY NUMBER
99999 = Unknown
Report 000000001 (Unknown) if not recorded in the patient's medical record
SERVICE DATE
Month
Day
Year (4-digit)
PREFERRED LANGUAGE SPOKEN
Enter a valid 3-letter PLS Code from either OSHPD's list of PLS Codes in the ED & AS Reporting Manual, Section 97267;
or from the ISO 639-2 Code List at www.loc.gov/standards/iso639-2
If the patient's language is not included in either of these lists, then enter the language spoken in the space provided.
EXPECTED SOURCE OF PAYMENT
09
11
12
13
14
16
AM
BL
CH
CI
Self Pay
Other Non-federal programs
Preferred Provider Organization (PPO)
Point of Service (POS)
Exclusive Provider Organization (EPO)
Health Maintenance Organization (HMO) Medicare Risk
Automobile Medical
Blue Cross/Blue Shield
CHAMPUS (TRICARE)
Commercial Insurance Company
OSHPD 1370.AS
DS
HM
MA
MB
MC
OF
TV
VA
WC
00
Disability
Health Maintenance Organization
Medicare Part A
Medicare Part B
Medicaid (Medi-Cal)
Other Federal program
Title V
Veterans Affairs Plan
Workers' Compensation Health Claim
Other
Revised May 1, 2014
AMBULATORY SURGERY
Page 2 of 3
DISPOSITION OF PATIENT
01
02
03
04
05
06
07
20
21
43
50
51
61
62
63
64
65
66
70
00
Discharged to home or self care (routine discharge)
Discharged/transferred to a short term general hospital for inpatient care
Discharged/transferred to skilled nursing facility (SNF) with Medicare certification in anticipation of covered skilled care
Discharged/transferred to a facility that provides custodial or supportive care (includes Intermediate Care Facility)
Discharged/transferred to a designated cancer center or children’s hospital
Discharged/transferred to home under care of organized home health service organization in anticipation of covered skilled care
Left against medical advice or discontinued care
Expired
Discharged/transferred to court/law enforcement
Discharged/transferred to a federal health care facility
Discharged home with hospice care
Discharged to a medical facility with hospice care
Discharged/transferred to a hospital-based Medicare approved swing bed
Discharged/transferred to an inpatient rehabilitation facility (IRF) including a rehabilitation distinct part unit of a hospital
Discharged/transferred to a Medicare certified long term care hospital (LTCH)
Discharged/transferred to a nursing facility certified under Medicaid (Medi-Cal), but not certified under Medicare
Discharged/transferred to a psychiatric hospital or psychiatric distinct part unit of a hospital
Discharged/transferred to a Critical Access Hospital (CAH)
Discharged/transferred to another type of health care institution not defined elsewhere in this code list
Other
PRINCIPAL DIAGNOSIS
ICD-9-CM CODE
OTHER DIAGNOSES
ICD-9-CM CODE
a.
g.
m.
s.
b.
h.
n.
t.
c.
i.
o.
u.
d.
j.
p.
v.
e.
k.
q.
w.
f.
l.
r.
x.
OTHER EXTERNAL CAUSES OF MORBIDITY
ICD-9-CM CODE
PRINCIPAL EXTERNAL CAUSE OF MORBIDITY
ICD-9-CM CODE
E
OSHPD 1370.AS
a.
E
b.
E
c.
E
d.
E
Revised May 1, 2014
AMBULATORY SURGERY
Page 3 of 3
PRINCIPAL PROCEDURE
CPT-4 CODE
OTHER PROCEDURES
CPT-4 CODE
a.
k.
b.
l.
c.
m.
d.
n.
e.
o.
f.
p.
g.
q.
h.
r.
i.
s.
j.
t.
OSHPD 1370.AS
Revised May 1, 2014
State of California – Health and Human Services Agency
Offi ce of Statewi de Health Planning and Development
Healthcare Information Division
Patient Data Section
400 R Street, Suite 270
Sacramento, California 95811-6213
(916) 326-3935; Fax (916) 322-9555
www.oshpd.ca.gov/HID/MIRCal/
Agent Designation Form
In order to designate a third party agent to submit data on your behalf, your facility must complete this form. All
information must be provided, including a signature from a facility administrator or primary contact.
Please print clearly
Section 1: Facility Information (all information is required)
1.
FACILITY ID NUMBER:
2.
FACILITY NAME:
3.
DATA TYPE(S):
Inpatient
Emergency Department
Ambulatory Surgery
Check one or more Data Type(s). If none are checked, the Agent will be given access to all Data Types associated with your facility.
4.
FACILITY BUSINESS ADDRESS (MAILING ADDRESS):
5.
FACILITY CONTACT NAME:
6.
TITLE:
7.
PHONE:
8.
E-MAIL ADDRESS:
Section 2: Designated Agent Information (all information is required)
9.
NAME OF DESIGNATED AGENT (COMPANY NAME):
10.
BUSINESS ADDRESS (MAILING ADDRESS):
11.
CONTACT NAME:
12.
PHONE:
13.
E-MAIL ADDRESS:
DESIGNATION EFFECTIVE DATE
14.
EFFECTIVE REPORT PERIOD BEGIN DATE:
Designation is effective until OSHPD receives written notification of
revocation or new designation.
By signing this document, I certify that I am an official of my facility and I am approving the aforementioned Designated
Agent to submit data on behalf of my facility for the designated data type(s) and effective date.
15.
NAME (PRINT):
17.
SIGNATURE:
OSH-HID 771 Rev. January 2011 (Formerly 1370.3)
16.
TITLE:
18.
DATE:
(916) 326-3935; Fax (916) 322-9555
PATIENT DATA REPORTING
EXTENSION REQUEST
Fax Request to: (916) 322-9555
Or (916) 327-1262
Attn: Patient Data Section
Date: ____________________
1. Facility Name:
2. Facility Identification Number:
3. Address:
4. Data Type:
Inpatient
Emergency Department
Ambulatory Surgery
5. Report Period Begin Date:
6. Report Period End Date:
7. Designated Agent (if applicable):
8. Number of Extension Days Requested:
9. Person Requesting Extension (print):
__________________________________________
10. Signature:
11. Title:
_______________________________________________________________________
12. Phone: _______________________________
OSH-HID 770 Rev. January 2011 (Formerly DD 1805)
E-mail: ______________________________
Office of Statewide Health Planning & Development
User Account Administrator (UAA) Agreement
Section 1: MIRCal User Account Administrator Information (all information is required)
1. FACILITY ID NUMBER:
2. FACILITY NAME:
3. NAME (FIRST, MIDDLE INITIAL, LAST AND CREDENTIALS):
4. POSITION (TITLE):
5. SUPERVISOR NAME:
6. BUSINESS ADDRESS (MAILING ADDRESS):
7. UNIQUE EMPLOYEE IDENTIFIER :
Note: An identifier that uniquely distinguishes you within your organization.
8. BUSINESS PHONE:
9. BUSINESS FAX:
10. E-MAIL ADDRESS:
11. AUTHENTICATION WORDS: Remember these words. You may be asked to identify yourself with this information if you call to reset your password.
a. Your mother’s maiden name:
b. Your city of birth:
I understand that as an appointed MIRCal User Account Administrator on behalf of the facility, I have the responsibility to:
1.
Create/add and inactivate user accounts for other MIRCal users within my facility. Creating a user account includes granting access roles for an
individual to read, submit and/or correct my facility’s confidential data. Removing granted access roles and/or inactivating user accounts revokes this
access.
2.
Modify the demographic information for my facility’s Primary, Secondary and Administrator Contacts. This notifies OSHPD of any changes in name,
mailing address, phone number, and e-mail address for each contact. Modifying contact demographic information directly changes the information on the
OSHPD database.
3.
Change passwords for MIRCal users within my facility. In the event that a user misplaces or forgets their password, they will be directed to contact their
User Account Administrator to have it reset. The User Account Administrator should authenticate the user prior to resetting the password and issuing a
new password.
4.
Unlock MIRCal user accounts. MIRCal will lock user accounts after three (3) unsuccessful log on attempts. When the account is locked, users will be
required to contact their User Account Administrator to unlock their account.
5.
Reactivate inactive accounts. NOTE: After 270 consecutive days (9 months) of inactivity, MIRCal user accounts may be inactivated.
By signing this document I acknowledge reading, understanding, and agreeing to its contents.
12. USER ACCOUNT ADMINISTRATOR SIGNATURE:
13. DATE:
Section 2: Facility Administrator Approval (all information is required) To be completed by the Facility Administrator (CEO or equivalent)
14. FACILITY ADMINISTRATOR NAME:
15. FACILITY ADMINISTRATOR SIGNATURE:
16. DATE:
17. PHONE NUMBER:
The completed form shall be sent to OSHPD for each User Account Administrator needing MIRCal UAA access. Fax (916) 327-1262 or (916) 322-9555
Section 3: For OSHPD use only
Date Received:
User Name:
Date Authenticated/Enrolled:
Note:
OSH-HID 773 Rev. February 2011 (Formerly 2002.1)
By:
Page 1 of 2
User Account Administrator (UAA) Agreement Instructions
Make a copy of the completed forms for your records. Send the completed form(s) to:
Office of Statewide Health Planning and Development
Sacramento, CA 95811-6213
Contact Information
Call your OSHPD Analyst or (916) 326-3920
E-mail mircal@oshpd.ca.gov
Fax (916) 327-1262 or (916) 322-9555
SECTION 1: MIRCal User Account Administrator Information (All fields must be completed) -- To be completed by the prospective MIRCal
User Account Administrator.
1.
Facility ID Number: Provide your OSHPD assigned 6 digit facility number.
2.
Facility Name: Provide the licensed name of your facility.
3.
Name and Credentials: Provide your full name and credentials (if applicable).
4.
Position (Title): Provide the position held at your facility.
5.
Supervisor Name: Provide the name of your supervisor/manager.
6.
Business Address (Mailing Address): Enter the business address where you can receive mail.
7.
Unique Employee Identifier: Provide an identifier that your facility uses that uniquely distinguishes you from other employees within your
organization. (I.e. title, badge number, employee number, etc.)
8.
Business Phone: Provide a phone number where you can be contacted.
9.
Business Fax: Provide a fax number where you can receive faxes.
10. E-mail address: Provide an e-mail address where you can be contacted.
11. Authentication Words: The authentication words provided may be used to identify you in the event that a password reset is required. It is
important to remember this information.
a. Provide your mother’s maiden name.
b. Provide your city of birth.
12. User Account Administrator Signature: If you acknowledge reading, understanding and agreeing to the contents of this document, provide your
signature.
13. Date: Provide the date that the facility agreement was completed and signed.
SECTION 2: Facility Administrator Approval (All fields must be completed) – To be completed by the Facility Administrator (CEO or equivalent).
This should be the person who directs the overall management of the facility. OSHPD will cross reference this name against the name supplied by
your facility as the MIRCal Facility Administrator contact person.
14. Facility Administrator Name: Print your name.
15. Facility Administrator Signature: After you have reviewed and approved the completed Facility User Account Administrator Agreement, you
must provide your signature indicating approval of person to act as the MIRCal User Account Administrator.
16. Date: Date of signature.
17. Phone Number: Provide a phone number where you can be reached.
SECTION 3: For OSHPD Use Only
Page 2 of 2
Designated Agent User Agreement
Section 1: MIRCal Designated Agent User Information (all information is required)
1.
DESIGNATED AGENT NAME
2.
NAME OF MIRCAL DESIGNATED AGENT USER (FIRST, MIDDLE INITIAL, LAST AND CREDENTIALS):
3.
POSITION (TITLE):
4.
SUPERVISOR NAME:
5.
BUSINESS ADDRESS (MAILING ADDRESS):
6.
UNIQUE EMPLOYEE IDENTIFIER:
Note: An identifier that uniquely distinguishes you within your organization.
7.
BUSINESS PHONE:
9.
E-MAIL ADDRESS:
8.
BUSINESS FAX:
AUTHENTICATION WORDS: Remember these words. You may be asked to identify yourself with this information if you call to reset your password.
a. Your mother’s maiden name:
b. Your city of birth:
10.
I understand that as a Designated Agent User:
1. I can submit data and retrieve the status of the data on behalf of a facility.
2. My MIRCal user account may be inactivated after 270 consecutive days (9 months) of inactivity. Only OSHPD can reactivate my account.
By signing this document I acknowledge reading, understanding, and agreeing to its contents.
11. DATE:
12. USER SIGNATURE:
Section 2: Designated Agent Primary Contact Approval (all information is required)
13.
PRINT NAME:
14.
DESIGNATED AGENT “PRIMARY” CONTACT SIGNATURE:
15.
DATE:
16.
PHONE NUMBER:
The completed form shall be sent to OSHPD for each Designated Agent user needing MIRCal access. Fax (916) 327-1262 or (916) 322-9555
Section 3: For OSHPD use only
Date Received:
User Name:
Date Authenticated/Enrolled:
Note:
By:
Please Note: The Facility Administrator or Primary Contact at each facility that you represent must complete and sign the Agent Designation Form (OSHPD
1370.3) approving a Designated Agent to submit data on their behalf.
Page 1 of 2
Designated Agent User Agreement Instructions
Make a copy of the completed forms for your records. Send the completed form(s) to:
Sacramento, CA 95811-6213
Contact Information
Call your OSHPD Analyst or (916) 326-3920
E-mail mircal@oshpd.ca.gov
Fax (916) 327-1262 or (916) 322-9555
SECTION 1: MIRCal Designated Agent User Information (All fields must be completed) -- To be completed by MIRCal User requesting access to
MIRCal.
1.
Name of Designated Agent: Provide the name of your business.
2.
Name and Credentials of MIRCal Designated Agent User: Provide the full name of the MIRCal user and credentials (if applicable).
3.
Position (Title): Provide the position held in your organization.
4.
Supervisor Name: Provide the name of your supervisor/manager.
5.
Business Address (Mailing Address): Enter the business address where you can receive mail.
6.
Unique Employee Identifier: Provide an identifier that your facility uses that uniquely distinguishes you from other employees within your
organization. (I.e. title, badge number, employee number, etc.)
7.
Business Phone: Provide a phone number where you can be contacted.
8.
Business Fax: Provide a fax number where you can receive faxes.
9.
E-mail address: Provide an e-mail address where you can be contacted.
10. Authentication Words: Remember these words. You may be asked to identify yourself with this information if you call to reset your password.
a. Provide your mother’s maiden name.
b. Provide your city of birth.
11. Date: Provide the date that the facility agreement was completed and signed.
12. User Signature: If you understand and agree with the responsibilities and guidelines for maintaining MIRCal security, as detailed in the user
agreement, provide your signature.
SECTION 2: Designated Agent Primary Contact Approval (All fields must be completed) – To be completed by the Designated Primary Contact.
13. Print Name: Print the name of the Designated Agent Primary Contact.
14. Designated Agent Primary Contact Signature: When the completed information is reviewed and approved, provide your signature indicating
approval of person to use MIRCal.
15. Date: Provide the date that this user agreement was approved and signed.
16. Phone Number: Provide a phone number where you can be reached.
SECTION 3: OSHPD Use Only
Page 2 of 2
(916) 326-3935; Fax (916) 322-9555
No Data to Report
1. Facility Name: ______________________________________________________________
2. Facility ID Number:
3. We do not have data to report for the above mentioned facility for the following reason(s):
a) Hospital Inpatient Care:
Report Period: From ____________________ to ____________________
We are not licensed to provide inpatient care effective: ____________________
We are licensed for inpatient care for this report period, but did not have any discharges as defined in
Section 97213(a) (1) of the California Code of Regulations.
b) Emergency Department:
We are not licensed to provide emergency department care effective: ____________________
We are licensed for emergency department services for this report period, but did not have any
encounters as defined in Section 97213(a) (2) of the California Code of Regulations.
c) Hospital-Based Ambulatory Surgery:
We did not perform procedures on an outpatient basis in a general operating room, ambulatory surgery
room, endoscopy unit or cardiac catheterization laboratory as defined in Section 97213(a) (3) of the
California Code of Regulations.
d) Freestanding Ambulatory Surgery Clinic:
We are not licensed by the State of California as a surgical clinic effective: _______________
We are licensed as a surgical clinic, but did not perform ambulatory surgery procedures for this report
period, as defined in Section 97213(a) (3) of the California Code of Regulations.
4. Additional Explanation: ____________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
5. Submitted by:
_______________________________________
______________________________________
Print Name
Title/Position
_______________________________________
______________________________________
Signature
Date
_______________________________________
______________________________________
Telephone
E-mail
OSH-HID 772 Rev. January 2011 (Formerly 2005.1)

OFFICE OF STATEWIDE HEALTH PLANNING AND DEVELOPMENT EMERGENCY DEPARTMENT

Transcription

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